Part III — Publication 5258 — Guide for Affordable Care

None	Checkbox indicating if Employer provided self- insured coverage.	If the employer is completing Part III, enter “0” or “1” in the check box in Part III. If the employer is not completing Part III, do not enter “1” in the check box in Part III.	CoveredIndividualInd
18a-30a	Name of covered individuals	The name of each covered individual.	CoveredIndiv idualGrp CoveredIndiv idualName PersonFirstN m PersonMiddle Nm PersonLastNm SuffxNm
18b/c- 30b/c	Covered Individuals	The 9-digit SSN for each covered individual. And The date of birth for the covered individual if SSN is blank.	Choice between SSN BirthDt
18d-30d	Annual or Monthly Coverage	Checkbox if the individual was covered for at least one day per month for all 12 months of the calendar year.	CoveredIndividualGrp CoveredIndividua lAnnualInd
18e-30e	Months of Coverage	Checkboxes indicating which months the individual was covered for at least one day if the individual was not covered for all 12 months of the calendar year.	CoveredIndividualGrp CoveredIndividual MonthlyInd JanuaryInd - DecemberInd

Guide for Electronically Filing ACA Information Returns for Software Developers and Transmitters 104

Data Mapping for ISS-UI Services/ISS-A2A Web Services

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Guide for Electronically Filing ACA Information Returns for Software Developers and Transmitters 105